President Trump calls for the re-establishment of mental asylums: A discussion of deinstitutionalization.

Following the school shooting in Florida at the end of February, President Trump advocated for the re-establishment of “mental asylums”, also known as psychiatric hospitals, citing a much-needed improvement of the mental health system and as a solution to gun violence in America. In order to contextualize the President’s claims, in this blog post, I’ll delineate a movement in the 1950’s known as deinstitutionalization and discuss the impact that had on our current mental health and criminal justice systems and policies.

Deinstitutionalization was the process of replacing long-stay psychiatric hospitals with community behavioral mental health services for individuals diagnosed with a mental disorder or developmental disability [1, 2, 3]. The movement took over a decade and can be broken down into a series of events: development of new psychotropic medications to treat symptoms of mental illness, the reallocation of federal dollars from state psychiatric hospitals to community mental health facilities, and President Kennedy’s 1963 call for mental health reform. Psychiatric hospitals were often poorly kept, understaffed, overcrowded, and lacked necessary resources to appropriately treat all patients. Deinstitutionalization occurred as a way to improve the treatment of institutionalized individuals suffering from mental illness.

The Criminal Justice System

As a result of deinstitutionalization, most individuals with mental illness were required to utilize private providers for services [4]. Those who could not afford private health insurance were forced out of hospitals and many ended up living on the street or were incarcerated [5], the rate of homelessness in the population of mentally ill is approximately 25%, compared to only 6% of the general population [6].The burden of care was therefore shifted from hospitals to the criminal justice practitioners and has subsequently led to increased exposure of the mentally ill community to law enforcement officers [7]. A study conducted in 1978 found that severely mentally ill persons who were hospitalized prior to deinstitutionalization were arrested three times more often compared to the general population, and five times more often in the case of violent crimes [8]. As a result of decades of disproportionately arresting mentally ill offenders, the criminal justice system incarcerates more individuals with mental illness than there are in state mental health hospitals. Some ways the criminal justice system has tried to correct the disproportionate incarceration of mentally ill offenders, has been through training of police officers and the increasing number of mental health courts. First, police departments around the country have implemented Crisis Intervention Teams (CIT) in an effort to train law enforcement officials to differentiate between criminal behavior and mental illness. programs are “hypothesized to improve officers’ abilities to effectively, respectfully, and safely interact with person with mental illness and subsequently divert them away from the criminal justice system and to mental health services” [9]. Second, Mental health courts are meant to identify offenders after arrest, and divert them to special courts that are designed to address underlying mental health issues to foster desistance from crime.

The Mental Health System

Currently, individuals typically seek mental health care through private or community mental health facilities. Private care is where an individual can seek out mental health treatment on their own, but may or may not accept insurance. Community mental health agencies are public locations where individuals can also seek treatment on their own. However, typically this is a location for individuals without health insurance or with no/low income. State mental health hospitals are the closest type of treatment facility to what was previously known as mental asylums. As a result of deinstitutionalization, and the creation of involuntary commitment to state mental health hospitals, the law requires that for admission an individual must be a danger to themselves, others, and/or are considered gravely disabled. The re-establishment of “mental asylums” would most likely make it easier to be institutionalized.

Deinstitutionalization was a movement that was multifaceted and had an effect across many sectors, from the criminal justice to mental health sectors. The current dilemma that the country faces is complex. The implementation of psychiatric hospitals, modeled after early twentieth century institutions would most likely take decades to accomplish, require changes to existing laws, and the reallocation of federal dollars across mental health and criminal justice system budgets. While there may be issues across criminal justice and mental health sectors, in identifying and treatment of mental illness, we have come a long way from the years of institutionalization of mentally ill individuals. Not only would more easily accessible in-patient state mental health treatment require many changes, it is not a panacea.

References

[1] Fakhoury, W., & Priebe, S. (2007). Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psychiatry, 6(8), 313-316.[2] Frank, R. G., & Glied, S. A. (2006). Better but not well: Mental health policy in the United States since 1950. JHU Press.[3] Grob, G. N. (1994). The mad among us: A history of the care of America’s mentally ill. Free Press.[4] Kennedy-Hendricks, A., Huskamp, H. A., Rutkow, L., & Barry, C. L. (2016). Improving access to care and reducing involvement in the criminal justice system for people with mental illness. Health Affairs, 35(6), 1076-1083.[5] Daniel, A. (2007). Care of the mentally ill in prisons: Challenges and solutions. Journal – American Academy of Psychiatry and the Law, 35(4), 406-410.[6] National Coalition for Homeless. (2009). Mental illness and homelessness. Retrieved from: http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf[7] Lamb, H. R., & Grant, R. (1982). The mentally ill in an urban county jail. Archives of General Psychiatry, 39(1), 17-32.[8] Sosowrsky, L. (1978). Crime and violence among mental patients reconsidered in view of the new legal relationship between the state and the mentally ill. American Journal of Psychiatry, 135(1), 33-42[9] Watson, A. C., Morabito, M. S., Draine, J., & Ottati, V. (2008). Improving police response to persons with mental illness: A multi-level conceptualization of CIT. International Journal of Law and Psychiatry, 31(4), 359-368.